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A. Based on direct observation and document review with the Facility representatives on 01/21/15, the surveyor observed that patient care areas are not separated from means of egress corridors which does not comply with 19.3.6. Lack of properly separated patient care areas from means of egress corridors could result in the inability of staff to confine a fire/smoke event and effectively evacuate patients from the area.

Findings include:

1. Corrected 07/23/15.

2. At 10:50AM on 01/22/2015, the 1st floor Emergency Department was observed to have exam rooms open to the corridor (non smoke tight curtains provided). This constitutes a patient care area open to the corridor. These areas do not comply with 19.3.6.1, Exception 1 (a).



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B. Based on observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the locations, as well as any staff and visitors present, because the lack of smoke detectors leaves the exit access corridors unprotected against early and prompt notification of a fire event that could render the exit access corridors unusable.

Findings include:

1. At 10:20am on 01/22/2015, 1st floor radiology/imaging area was observed to have dressing - waiting areas open to the corridor (non smoke tight curtains provided) which are not staffed 24/7. These areas are not otherwise provided with smoke detection to comply with 19.3.6.1, Exception No. 1 (c).

Based on observation during the survey walkthrough not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This condition may affect patients, staff and visitors on the upper floors from a safe means of egress during a fire/smoke event.

Findings include:

A. 01/21/2015 at 10:15am 1st floor Exit Stair # 2 a designated 2-hour enclosed/separated Exit stair is not separated to comply with 19.3.1.1, 7.1.3.2.1 (e)Conditions observed include:

1. REVISED 07/23/15: A sprinkler pipe was observed, above the door at the First Floor landing, that is not sealed against the passage of fire in accordance with 8.2.3.2.4.2.

2. REVISED 07/23/15: An insulated heating pipe was observed, above the door at the First Floor landing, that breaches the wall of the enclosure, in a manner prohiited by 8.2.2.2, AND whichy is not separated from the exit enclosure as required by 7.1.3.2.1(e).

B. Corrected 07/23/15.

C. Corrected 07/23/15.




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During the survey walk-through, accompanied by facility staff, it was observed that exit access is not arranged so that exits are readily discernable at all times in accordance with 18.2.1. This deficiency could affect the ability of patients, staff, and visitors in the smoke compartment of fire origin to choose the proper path of egress.

Findings include:

A. Corrected 07/23/15.

B. NEW ITEM 07/23/15: At 10:15 AM on July 23, 2-15, while accompanied by the provider's Director of Engineering/Construction, the surveyor observed that the Second Floor West Pavilion Corridor, as measured from the north end of the Staff Elevator Lobby to the primary North-South Corridor in the West Pavilion, constitutes a dead end corridor in excess of 30'-0" as prohibited by 18.2.5.10.

AC. NEW ITEM 07/23/15: At 10:15 AM on July 23, 2-15, while accompanied by the provider's Director of Engineering/Construction, the surveyor observed that the pair of doors south and west of the Staff Elevator Lobby is secured against egress to the west but is identified by an exit sign as an egress path in that direction as prohibited by 7.10.

Based on direct observation during the survey walk-through, with the Maintenance Supervisor and staff maintenance, the surveyor find that not all portions of the building fire protection systems and materials are installed and maintained in accordance with NFPA 13 - 1999.

Findings include:

A. Corrected 07/23/15.

B. The following rooms were observed to lack sprinkler protection:

1. Corrected 07/23/15.

2. Corrected 07/23/15.

3. NEW ITEM 07/23/15: At 1:10 PM on July 23, 2015, while accompanied by the provider's Director of Engineeering/Construction, the surveyor observed that the South Paviliion IT Closet, adjacent to the Cancer Center Entry Vestibule, lacked a ceiling and had perimeter walls which do not extend to the deck above, thus compromising sprinkler protection in a manner prohibited by NFPA 13 1999 5-6.4.1.1.



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C. Corrected 07/23/15.



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Based on observation during the survey walk, while accompanied by facility staff, failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed response during a fire event, which could affect patients, staff and visitors.
Findings include:

A. By direct observation 1/20/15 at 9:00 AM while in the company of the Director of Engineering / Construction the surveyor find the Generator Room W2664 is not provided with a sprinkler fire suppression system. NFPA 13, 1999, 1-6.1 & 13, 5-1.


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B. Corrected 07/23/15.

Based on observation during the survey walk, while accompanied by facility staff, failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed response during a fire event, which could affect patients, staff and visitors. The installation does not comply with NFPA 13 1999

Findings include:

A. Corrected 07/23/15.

B. By direct observation 1/21/15 at 1:45 PM while in the company of the Director of Engineering / Construction the surveyor find the IT / Communications and Electrical closets on 4th Floor are not provided with fire suppression. (NFPA 13, 1999, 1-6.1 & 13, 5-1.)

C Corrected 07/23/15.

D. Corrected 07/23/15.

E. Corrected 07/23/15.



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F. Corrected 07/23/15.

This STANDARD is not met as evidenced by:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the
survey walk-through, the provider shall institute the appropriate Interim Life Safety Measures
until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan
of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all
such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the Interim Life Safety Measures to remain in place as work toward the completion of its PoC progresses.

This STANDARD is not met as evidenced by:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute the appropriate Interim Life Safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all
such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the Interim Life Safety Measures to remain in place as work toward the completion of its PoC progresses.

Based on observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the hospital if the emergency power system does not operate correctly.

Findings include:

A. On Wednesday, January 21, 2015 at approximately 10:20 A.M. the surveyor observed that the transfer switch in the electrical room on the lower level of the north pavilion served by substation #1 was serving a distribution panel that served loads from all branches of emergency power. NFPA-70, Section 517-30 requires that each branch of the essential electrical system be served by one or more transfer switches when the essential electrical system demand exceeds 150KVA.

B. On Wednesday, January 21, 2015 at approximately 10:00 A.M. the surveyor observed that the EM panel on each floor of the north pavilion was serving a mixture of life safety, critical and equipment loads. For example panel EM-60-M1 was serving mostly life safety loads, but was serving a board room heater on circuit 35. These panels were also served from a distribution panel on the lower level that was served from a single transfer switch and served all branches of emergency power.

Based on direct observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect any patient if the transfer switch serving these rooms fails.

Findings include:

A. On Wednesday, January 21, 2015 at approximately 2:00 PM the surveyor observed that the operating rooms were not equipped with normal receptacles to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.

B. On Wednesday, January 21, 2015 at approximately 2:20 PM the surveyor observed that the PACU was not equipped with normal receptacles at the headwall of each bed location to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.

C. On Wednesday, January 21, 2015 at approximately 1:45 PM the surveyor observed that the cab lighting for the hydraulic elevator serving the cancer center was not served from the life safety panel as required by NFPA-70, Section 517-32, and there was not a disconnect switch for cab lighting and controls within the elevator equipment room as required by NFPA-70, Section 620-22. This could affect any occupant of the building using the elevator during a power outage.

Based on observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

A. On Wednesday, January 21, 2015 at approximately 9:00 A.M. the surveyor observed that the elevator cab lights in the penthouse of the knuckle area of the north pavilion for elevators D, E, and F were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32.

B. On Wednesday, January 21, 2015 at approximately 9:45 A.M. the surveyor observed that the elevator cab lights for elevator H in the north pavilion were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32, and they were not equipped with a disconnect in the elevator equipment room in accordance with NFPA-70, Section 620-53.

Based on observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the elevators did not meet all of the requirements of ANSI/ASME A17.3. This could affect any occupants of the facility using the elevator if proper safety equipment is not installed on each elevator.

Findings include:

A. The north pavilion elevator machine room for elevator H did not have a heat detector within 2' of each sprinkler head tied to a shunt trip as required by NFPA-72, Section 3-9.4, and ASME A17.1, Section 102.2(c)(3).